An international comparison of cancer survival: metropolitan Toronto, Ontario, and Honolulu, Hawaii

Am J Public Health. 2000 Dec;90(12):1866-72. doi: 10.2105/ajph.90.12.1866.


Objectives: Comparisons of cancer survival in Canadian and US metropolitan areas have shown consistent Canadian advantages. This study tests a health insurance hypothesis by comparing cancer survival in Toronto, Ontario, and Honolulu, Hawaii.

Methods: Ontario and Hawaii registries provided a total of 9190 and 2895 cancer cases (breast and prostate, 1986-1990, followed until 1996). Socioeconomic data for each person's residence at the time of diagnosis were taken from population censuses.

Results: Socioeconomic status and cancer survival were directly associated in the US cohort, but not in the Canadian cohort. Compared with similar patients in Honolulu, residents of low-income areas in Toronto experienced 5-year survival advantages for breast and prostate cancer. In support of the health insurance hypothesis, between-country differences were smaller than those observed with other state samples and the Canadian advantage was larger among younger women.

Conclusions: Hawaii seems to provide better cancer care than many other states, but patients in Toronto still enjoy a significant survival advantage. Although Hawaii's employer-mandated health insurance coverage seems an effective step toward providing equitable health care, even better care could be expected with a universally accessible, single-payer system.

Publication types

  • Comparative Study
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Adult
  • Aged
  • Breast Neoplasms / mortality*
  • Breast Neoplasms / therapy
  • Confounding Factors, Epidemiologic
  • Female
  • Hawaii / epidemiology
  • Health Benefit Plans, Employee / statistics & numerical data
  • Health Services Research
  • Humans
  • Income / statistics & numerical data
  • Insurance Coverage / statistics & numerical data*
  • Insurance, Health / classification
  • Insurance, Health / statistics & numerical data*
  • Male
  • Middle Aged
  • National Health Programs / statistics & numerical data
  • Ontario / epidemiology
  • Prostatic Neoplasms / mortality*
  • Prostatic Neoplasms / therapy
  • Quality of Health Care*
  • Single-Payer System / statistics & numerical data
  • Socioeconomic Factors
  • Survival Analysis
  • Universal Health Insurance / statistics & numerical data
  • Urban Health / statistics & numerical data*